A nurse is planning to administer a tuberculin skin test to a client who has had an exposure to tuberculosis. Which of the following actions should the nurse plan to take?

Inject 0.3 to 0.5 mL of the solution.

Select an injection site that is free of scar tissue.

Hold the needle at a 30° angle during injection.

Massage the site following the injection.

Answer and Explanation

The Correct Answer is B

A. Inject 0.3 to 0.5 mL of the solution: The typical volume for a tuberculin skin test is 0.1 mL.
B. Select an injection site that is free of scar tissue: Scar tissue can interfere with the reading of the tuberculin skin test, so a site free of scars should be selected.
C. Hold the needle at a 30° angle during injection: The needle should be held at a 5–15° angle for intradermal injections.
D. Massage the site following the injection: Massaging the site is not recommended as it could affect the accuracy of the test.

Nursing Test Bank

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Correct Answer is A

Explanation

A. Use the Z-track technique to administer the medication.: The Z-track technique prevents irritation by sealing the medication within the muscle tissue.
B. Administer the medication with a 27-gauge 1/2-inch needle.: IM injections require a longer needle, typically 1–1.5 inches, and a larger gauge, such as 21–25.
C. Inject the medication at least 5 cm (2 in) from the umbilicus.: This is relevant for subcutaneous injections, not IM injections.
D. Give the medication without aspirating prior to injection.: Aspiration is not always required for IM injections but is often practiced for safety when administering certain medications.

A. Tachycardia B. Sedation C. Dilated pupils D. Tachypnea

Correct Answer is B

Explanation

A. Tachycardia: Bradycardia, rather than tachycardia, is more typical of opioid toxicity.
B. Sedation: Oxycodone toxicity causes CNS depression, resulting in sedation, respiratory depression, and pinpoint pupils.
C. Dilated pupils: Pinpoint pupils are a classic sign of opioid toxicity.
D. Tachypnea: Respiratory depression, rather than tachypnea, is expected in opioid toxicity.

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Prescribed Medication	Nursing Instruction
Albuterol	"Take your albuterol when you are having difficulty breathing.” "Hold your breath for 20 seconds when taking your albuterol.”
Salmeterol	"Take the salmeterol 5 minutes before the albuterol when you need both medications." "Take the salmeterol 2 times each day."
Fluticasone	"Rinse out your mouth after taking the fluticasone." "Take the fluticasone as needed for an asthma attack."

A nurse is planning to administer a tuberculin skin test to a client who has had an exposure to tuberculosis. Which of the following actions should the nurse plan to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer an IM injection to a client who has gonorrhea. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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